Laparoscopic Radical Cystectomy with Ileal Conduit
Diversion: The First Case Report in Thailand
Kittinut Kijvikai MD*, Suthep Patcharatrakul MD**,
Wisoot Kongchareonsombat MD***, Charuspong Dissaranan MD*
* Division of Urology, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
** Division of Urology, Department of Surgery, Police General Hospital
*** Division of Urology, Department of Surgery, Bangkok Metropolitan Administration Medical College
and Vajira Hospital
Objective: To report the authors’ first experience on a surgical technique for laparoscopic radical cystectomy
with ileal conduit diversion.
Material and Method: A 55 year-old man, weighing 65 Kg with histology proven T 2 transitional cell
carcinoma of the urinary bladder underwent laparoscopic radical cystectomy with ileal conduit diversion.
The cystoprostatectomy was performed by laparoscopic technique, whereas ileal conduit and stroma were
performed through a mini-laparotomy.
Results: The procedure was performed successfully without open conversion. The operation time was 350 min.
Estimated blood loss was 1,100 ml. Only 6 mg morphine was needed for postoperative pain relief. The surgical
margins were free from tumor. The hospital stay was 8 days. The patient returned to his normal activities 3
weeks after surgery.
Conclusion: Laparoscopic radical cystectomy with ileal conduit diversion was a feasible and safe operation
for muscle invasive carcinoma of the urinary bladder. However, the procedure needed a steep learning curve
and should be performed in centers having experience in laparoscopic surgery.
Keywords: Radical cystectomy, Ileal conduit diversion, Laparoscopy
J Med Assoc Thai 2005; 88 (12): 1947-51
Full text. e-Journal: http://www.medassocthai.org/journal
Radical cystectomy is the gold standard treat- radical cystectomy and ileal conduit urinary diversion
ment for invasive bladder cancer(1). However, it is a in a male patient.
major surgical procedure and may incur significant
operative blood loss. Laparoscopic cystectomy has Case Report
been described and it has been proven to be feasible(2,3). Case history
Nevertheless, its role, advantages and potential com- A 55-year-old man with no underlying disease
plications should be defined. The technical aspects of presented with 4 months’ history of painless gross
laparoscopic cystectomy are not well standardized hematuria. A cystoscopy revealed a multiple sessile
and most operations are performed in well equipped bladder tumor, 2-3 cm in diameter, involving the ante-
centers for laparoscopic surgery. rior, posterior, left and right lateral bladder wall. A com-
In the present report, the authors describe puted tomography (CT) scan of the abdomen and
the technique for the first successful laparoscopic pelvis confirmed the presence of the lesion without
any evidence of metastatic disease. A transurethral
Correspondence to : Kijvikai K, Division of Urology, Department resection of the bladder tumor (TUR-BT) was performed
of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol
University, 270 Rama 6 Rd, Tungphyatai, Rajathevee, Bangkok
and the pathology report was consistent with a G 2 T 2
10400, Thailand. Phonn: 0-2201-1315, Fax: 0-22011316, transitional cell carcinoma of the bladder. After having
E-mail: firstname.lastname@example.org been explained about the risk, benefits, and possible
J Med Assoc Thai Vol. 88 No. 12 2005 1947
complications of different therapeutic options, the establishment of the pneumoperitoneum. The abdo-
patient signed consent to undergo a laparoscopic men and pelvis were then carefully inspected.
radical cystectomy with ileal conduit urinary diversion.
2. Denonvilliers’ fascia incision
Technique The peritoneum was incised at the level of
Patient’s preparation the rectovesical cul-de-sac and the vas deferens were
The patient received a standard bowel prepa- identified and divided bilaterally. Dissection was per-
ration with electrolytes on the day before the surgical formed toward Denonvilliers’ fascia and the tips of the
procedure. He was given an antibiotic for prophylaxis seminal vesicles. After identification of Denonvilliers’
with a second generation cephalosporin (cefoxitin 1 g x fascia, the fascia was incised in the midline to expose
2) at the induction of anesthesia which was continued the perirectal fat. The fibers of the rectum were bluntly
for 24 postoperative hours. Lower extremities compres- pushed away posteriorly from the prostate by laparo-
sive devices were applied before starting the proce- scopic fan retractor. This dissection was carried down
dure. The patient was placed in the modified lithotomy as far as possible to the apex of the prostate. The semi-
abducted-thighs and Trendelenburg position, while nal vesicles and vas deferens were then mobilized en
a nasogastric tube was inserted and a 18 Fr. Foley bloc with bladder specimen. Complete mobilization of
catheter was placed for drainage of the urine. the rectum was crucial in order to better define the
prostatic and vesical pedicles and to prevent rectal
Surgical technique injuries.
1. Laparoscopic access The ureters were dissected down to the blad-
A 5-port transperitoneal approach was used der wall with care to keep their vascular supply intact
(Fig. 1). The first 12-mm trocar was placed with open and the distal ureteral margins were sent for pathologic
technique through a mini-laparotomy just below the frozen section examination.
umbilicus. This trocar was reserved for the laparoscope.
The remaining 4 (12-mm x 3, 5-mm x 1) ports were placed 3. Exposure of endopelvic fascia and dorsal venous
in a fan-shape fashion under endoscopic control after complex control
Incision of the peritoneum was carried out
along the external iliac artery and extended distally to
the abdominal wall lateral to the umbilical ligaments,
and proximally to the common iliac artery. At the level
of the pubic bone, the bladder and perivesical fat were
dissected freely from the pelvic wall with exposure of
the endopelvic fascia. The fascia was incised closely
to the prostate bilaterally and the fibers of the levator
muscle was carefully dissected. The dorsal vein com-
plex and the prostatic apex were then carefully iso-
A 1-0 Monocryl absorbable suture was
passed and encircled two rounds over the dorsal vein
complex and the dorsal vein complex was then ligated.
4. Vesical and prostatic pedicles incision
At this time the assistant surgeon pulled the
bladder upward and toward the right side of the pelvis
by using a grasper with the left hand, while in the
Fig. 1 A picture showing 5 ports placement in a fan-shaped
meantime with the right hand he pushed with the fan
fashion for cystoprostatectomy and a laparotomy
retractor downward the rectum in order to expose the
incision for both specimen extraction and extracor-
poreal ileal conduit reconstruction. The 0 and 30 left vesicoprostatic pedicle. With the use of LigaSure
degree laparoscope was inserted through the umbili- device and bipolar forceps the vesical and prostatic
cal port. The right pararectus muscle port was chosen pedicles were progressively divided. Then, the blad-
to be the stromal site of the conduit der was pulled by the surgeon on the left side while the
1948 J Med Assoc Thai Vol. 88 No. 12 2005
fan retractor continued to push the rectum downward duit diversion and bilateral Bricker ureteroileal anas-
in order to divide the right vascular pedicle in the same tomosis. The estimated blood loss was 1,100 ml, and 4
manner as the left side. units of blood transfusion were replaced.
The patient resumed oral intake on the third
5. Apex incision postoperative day. A total of 6 mg of morphine was
After ligation, the dorsal vein complex was used for pain relief. The drain was removed on day-5.
then divided and the anterior urethral wall was incised. The ureteral stents were removed on postoperative
The distal end of the catheter was ligated, transected day-7. He was discharged from the hospital on post-
and pulled into the abdominal cavity, maintaining the operative day-8.
balloon inflated in the bladder to avoid intraabdominal Histopathology showed muscle invasive TCC
urine contamination. The posterior wall of the urethra of the bladder without lymph node metastasis. The
was divided. The rectourethralis muscle and the distal surgical margins were free. The total number of pelvic
insertions of Denonvilliers’ fascia were incised in order lymph nodes dissection was 7 on the left side and 10
to totally release a specimen which was then entrapped on the right side, respectively. A follow-up serum creati-
in an endosac bag. nine and electrolytes were within normal limits. After 3
weeks, the patient could return to his normal activities.
6. Bilateral pelvic lymph node dissection
A bilateral pelvic lymph node dissection was Discussion
performed with the same boundaries as in an open Open radical cystectomy is the gold standard
surgery. of treatment for muscle invasive bladder cancer(1). This
operation requires a long abdominal incision with pro-
7. Specimen retrieval and creation of the ileal conduit longed retraction of the abdominal wall. This maneu-
A 7-cm incision was then performed at the ver leads to a high level of postoperative pain, often re-
lower midline, starting from the umbilicus (Fig. 1). The quiring a large amount of opioid medication for several
specimen was retrieved and the suspended sutures of days. Consequently, the patients remain hospitalized
the ureters were exteriorized. The distal ileum was iden- with continuing care for a long time and need a long
tified and brought in front of the abdominal wall. A period of rest before returning to the normal activities.
segment of 15-cm ileum proximal to ileocecal valve was All of these may cause fear among patients and sur-
isolated with GIA stapler. The continuity of the bowel geons, and these can also make the patients postpone
was re-established performing a functional double layer the operation, which may result in a worsening prog-
end-to-end anastomosis using 3-0 Monocryl absorb- nosis.
able suture. The mesentery was reapproximated using Several authors(4-8) have demonstrated that
absorbable sutures and the distal ileum relocated in laparoscopic cystectomy is feasible with lower mor-
the abdomen. The distal ureters were brought in the bidity and shorter hospital stay than the open proce-
operative field. The spatulated ureters were stented dure. Some authors have reported a lower incidence of
and anastomosed in a Bricker fashion to the ileal con- postoperative ileus after the laparoscopic approach
duit utilizing 4-0 Monocryl sutures. The proximal end when compared with the open surgery approach,
of the conduit was replaced in the abdomen. The right principally due to less manipulation of the bowel and
pararectus muscle port was chosen to be the stomal site. fewer opioids are necessary to control pain postopera-
Pneumoperitoneum was reestablished and tively(9,10). Moreover, magnification of the optical in-
the proper placement of the ileal conduit was confirmed. strumentation can enable more precise dissection with
A small drain was left in the pelvis. The fascia of the 10 less blood loss and better preservation of anatomical
mm port site was closed under direct vision with 1-0 structures(11). Laparoscopic cystectomy with different
Vicryl absorbable suture. The pneumoperitoneum was types of urinary diversions has been reported by
released and the procedure was completely finished. numerous authors(4-9,11-15).
In the present report, the authors have
Results shown their first experience in the cystectomy step. All
The laparoscopic procedure was completed authors utilized a transperitoneal approach with 4
without intraoperative complications or need for open ports(5,6) ports(7,9,12-15) or 6 ports(8). The authors have
conversion. The total operative time was 350 min; 230 been using 5 ports in a fan-shape fashion. Lympha-
minutes for cystectomy and 120 minutes for ileal con- denectomy was performed after cystectomy which was
J Med Assoc Thai Vol. 88 No. 12 2005 1949
the same as that of some authors(6,8) However, the better preservation of anatomical structures. Laparo-
others have performed before(7,9,12,14,15) or in the middle scopic radical cystectomy should therefore be the
of the procedure(13). The authors dissected the posterior operation for experienced laparoscopic surgeons. But
part of the bladder first by following the vas deferens in the authors’ opinion, this procedure may be prac-
and seminal vesicle. The lateral and posterior vascular ticed in every academic center. The results from the
pedicles of the bladder and prostate are controlled with presented technique described in this report are en-
sequential firings of the Endo-GIA stapler by many couraging and it is believed that a better outcome can
authors(6-10,13-15), but in the authors’ opinion multiple be obtained if more experience is gained.
firings of the Endo-GIA stapler may result in increasing
the costs of the operation without reduction in opera- Acknowledgement
tive time. So, the authors have been using the LigaSure The authors wish to thank Professor Amnuay
device with the help of bipolar forceps and Hem-o-lok Thithapandha for his help and advice concerning the
5 and 10 mm to provide a precise dissection and an preparation of this manuscript.
excellent control of vascular pedicles. In some reported
series(7,12-14) the vesical and prostatic fibrovascular References
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้ ั ้ ่
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กิตติณฐ กิจวิกย, สุเทพ พัชรตระกูล, วิสตร คงเจริญสมบัต,ิ จรัสพงศ์ ดิศรานันท์
รายงานการผ่าตัดกระเพาะปัสสาวะในผู้ชายแบบเรดิคัล ในผู้ป่วยมะเร็งกระเพาะปัสสาวะ โดยใช้การผ่าตัด
ผ่านกล้อง สำเร็จเป็นรายแรกของคณะแพทยศาสตร์โรงพยาบาลรามาธิบดี และเป็นรายงานแรกในประเทศไทย
โดยมีการวิเคราะห์เกี่ยวกับเทคนิคการผ่าตัด ผลการรักษา โดยเทียบเคียงกับวารสารทางการแพทย์ของต่างประเทศ
J Med Assoc Thai Vol. 88 No. 12 2005 1951